This phase III clinical trial is studying how well giving tamoxifen citrate, anastrozole, letrozole, or exemestane with or without chemotherapy works in treating patients with invasive breastcancer. Estrogen can cause the growth of breastcancer cells. Hormone therapy, using tamoxifen citrate, may fight breastcancer by blocking the use of estrogen by the tumor cells. Aromatase inhibitors, such as anastrozole, letrozole, and exemestane, may fight breastcancer by lowering the amount of estrogen the body makes. Drugs used in chemotherapy work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. It is not yet known whether giving tamoxifen citrate, anastrozole, letrozole, or exemestane is more effective with combination chemotherapy in treating patients with breastcancer.

RS, as measured by Oncotype DX [ Time Frame: Up to 15 years ] [ Designated as safety issue: No ]

The interaction of the linear RS term and chemotherapy benefit will be tested in a Cox regression model of DFS. If the interaction is statistically significant and there is a point of equivalence between the two randomized treatments for some RS value in the range 0-25, a clinical cutpoint for recommending chemotherapy will be estimated. This estimated cutpoint is the upper bound of the 95% confidence interval on the point of equivalence. Kaplan-Meier curves comparing randomized arms generated separately for RS values below and above this cutpoint and tested with stratified log-rank tests.

Secondary Outcome Measures:

OS [ Time Frame: The time from the second registration (randomization) to death due to any cause, assessed up to 15 years ] [ Designated as safety issue: No ]

DDFS [ Time Frame: The time from second registration to distant recurrence, new invasive primary, or death due to any cause, assessed up to 15 years ] [ Designated as safety issue: No ]

Local disease-free interval [ Time Frame: The time from second registration to local/regional recurrence, assessed up to 15 years ] [ Designated as safety issue: No ]

Toxicities using standard National Cancer Institute (NCI)-Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 [ Time Frame: Up to 5 years ] [ Designated as safety issue: Yes ]

Patients receive a protocol-approved chemotherapy regimen based on the patient and/or physician preference. Patients then receive a protocol-approved adjuvant endocrine therapy comprising tamoxifen citrate, an aromatase inhibitor (anastrozole, letrozole, or exemestane), or both for 5-10 years in the absence of disease progression or unacceptable toxicity.

Drug: Systemic Chemotherapy

Given IV

Drug: Tamoxifen Citrate

Given PO

Other Names:

ICI 46,474

ICI-46474

Drug: Anastrozole

Given PO

Other Names:

ANAS

ICI-D1033

ZD-1033

Drug: Exemestane

Given PO

Other Names:

Aromasin

FCE-24304

PNU 155971

Drug: Letrozole

Given PO

Other Names:

CGS 20267

Femara

LTZ

Other: Laboratory Biomarker Analysis

Correlative studies

Other: Quality-of-Life Assessment

Ancillary studies (closed as of 12/1/12)

Other Name: Quality of Life Assessment

Experimental: Arm II (endocrine therapy)

Patients receive a protocol-approved endocrine therapy comprising tamoxifen citrate, an aromatase inhibitor (anastrozole, letrozole, or exemestane), or both for 5-10 years in the absence of disease progression or unacceptable toxicity.

Patients must have a histologically confirmed diagnosis of node positive (1-3 nodes) invasive breast carcinoma with positive estrogen and/or progesterone receptor status, and negative HER-2 status; estrogen and progesterone receptor positivity must be assessed according to American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) guidelines as either estrogen receptor (ER) or progesterone (PR) >= 1% positive nuclear staining; HER-2 test result negativity must be assessed as per ASCO/CAP 2013 guidelines using immunohistochemistry (IHC), in situ hybridization (ISH) or both; HER-2 is negative if a single test (or all tests) performed in a tumor specimen show: a) IHC negative (0 or 1+) or b) ISH negative using single probe or dual probe (average HER-2 copy number < 4.0 signals per cell by single probe or HER-2/CEP ration < 2.0 with an average copy number < 4.0 signals per cell by dual probe); if HER-2 IHC is 2+, evaluation for gene amplification (ISH) must be performed and the ISH must be negative; ISH is not required if IHC is 0 or 1+; HER-2 equivocal is not eligible

Multifocal disease is defined as more than one invasive cancer < 2 cm from the largest lesion within the same breast quadrant; (NOTE: The Oncotype DX testing must be completed on the largest lesion)

Multicentric disease is defined as more than one invasive cancer >= 2 cm from the largest lesion within the same breast quadrant or more than one lesion in different quadrants (NOTE: Oncotype DX testing should be completed on all tumors and the determination for eligibility should be made on the highest recurrence score)

Synchronous bilateral disease is defined as invasive breast cancer with positive lymph nodes (axillary or intramammary) in at least one breast, diagnosed within 30 days of each other; (NOTE: The Oncotype DX testing should be completed on both tumors and the tumor with the highest recurrence score should be used)

Patients will have undergone axillary staging by sentinel node biopsy or axillary lymph nodes dissection (ALND); patients must have at least one, but no more than three known positive lymph nodes (pN1a, pN1b or pN1c); patients with micrometastases as the only nodal involvement (pN1mi) are not eligible; patients with positive sentinel node are not required to undergo full axillary lymph node dissection; this is at the discretion of the treating physician; axillary node evaluation is to be performed per the standard of care at each institution

Patients must not have inflammatory breast cancer and must not have metastatic disease; patients with a prior diagnosis of ductal carcinoma in situ (DCIS) are eligible if they received mastectomy alone (no therapeutic radiation, intraoperative radiation, or endocrine therapy); radiation in the opposite breast is acceptable; partial breast irradiation (including brachytherapy) is not allowed

Patients must have had breast-conserving surgery with planned radiotherapy or total mastectomy (with or without planned post mastectomy radiation); patients must have clear margins (as per local institutional guidelines)

Registration of patients who have not yet undergone Oncotype DX screening must occur no later than 56 days after definitive surgery; (for all patients, Step 2 Registration must occur within 84 days after definitive surgery); if the Oncotype DX Breast Cancer Assay has not been performed, patients must be willing to submit tissue samples for testing to determine the Recurrence Score value; a representative block or unstained sections from the representative block are sent directly to Genomic Health for Oncotype DX Breast Cancer Assay which will be performed according to the standard commercial process

If the Oncotype DX Recurrence Score is already known and is 25 or less, the patient must be registered to Step 2 immediately following Step 1 registration; if the Oncotype DX Recurrence Score is already known and is greater than 25, the patient is ineligible

Patients must have a complete history and physical examination within 28 days prior to registration

Patients must have a performance status of 0-2 by Zubrod criteria

Patients must be able to receive taxane and/or anthracycline based chemotherapy

Patients must not have begun chemotherapy or endocrine therapy for their breast cancer prior to registration

Patients must not require concurrent chronic treatment with systemic steroids (inhaled steroids are allowed) or other immunosuppressive agents

Patients must not have received an aromatase inhibitor (AI) or a selective estrogen receptor modulator (SERM) such as tamoxifen or raloxifene within 5 years prior to registration

Patients must not be pregnant or nursing; women of reproductive potential must have agreed to use an effective contraceptive method; a woman is considered to be of "reproductive potential" if she has had menses at any time in the preceding 12 consecutive months; in addition to routine contraceptive methods, "effective contraception" also includes heterosexual celibacy and surgery intended to prevent pregnancy (or with a side-effect of pregnancy prevention) defined as a hysterectomy, bilateral oophorectomy or bilateral tubal ligation; however, if at any point a previously celibate patient chooses to become heterosexually active during the time period for use of contraceptive measures outlined in the protocol, he/she is responsible for beginning contraceptive measures

No other prior malignancy is allowed except for adequately treated basal cell (or squamous cell) skin cancer, in situ cervical cancer, or other cancer for which the patient has been disease-free for 5 years

The Quality of Life and Economic Substudy is permanently closed to accrual effective 12/1/12; patients who consented to QOL prior to 12/1/12 should continue to complete QOL forms per their expectation report; patients who are able to complete a questionnaire in English must be offered the opportunity to participate in the Quality of Life and Economic Substudy. (The Quality of Life and Economic Substudy is available to U.S. INSTITUTIONS ONLY); patients who are not able to complete a questionnaire in English are registered to S1007 without participating in the Quality of Life and Economic Substudy

Patients who consent to participate in the Quality of Life and Economic Substudy and who do not yet know the results of their Oncotype DX screening must agree to complete the S1007 Health-Related Quality of Life Questionnaire: Enrollment between 14 days prior to and 7 days after Step 1 Registration

Patients who consent to participate in the Quality of Life and Economic Substudy and who do already know their Oncotype DX Recurrence Score (and it is 25 or less) will proceed to Step 2 Registration without completing the S1007 Health-Related Quality of Life Questionnaire Enrollment Form (but will complete the S1007 Health-Related Quality of Life Questionnaire: Randomized Study Form)

Patients or their legally authorized representative must be informed of the investigational nature of this study and must sign and give written informed consent in accordance with institutional and federal guidelines; for Step 1 registration of patients who have not yet submitted specimens for the Oncotype DX Breast Cancer Assay, the appropriate consent form is the Step 1 Consent Form; for both Step 1 and Step 2 registration of patients whose Recurrence Score is already known and is 25 or less, the appropriate consent form is the Step 2 Consent Form

As a part of the OPEN registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system

Recurrence score (RS) by Oncotype DX must be =< 25

Step 2 Registration must take place within 84 days after definitive surgery; patients must not have begun chemotherapy or endocrine therapy for their breast cancer prior to randomization

Patients randomized to either arm may also co-enroll in Phase III trials that compare local therapies, or compare systemic therapies (not including chemotherapy); patients randomized to chemotherapy may also co-enroll in Phase III trials that compare chemotherapies (including S1207)

Contacts and Locations

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study.
To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below.
For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01272037